Synergistic pharmaceutical combination for the prevention or treatment of diabetes

ABSTRACT

The invention refers to a synergistic pharmaceutical combination which comprises (a) a first pharmaceutical composition containing an antidiabetic or anti-hyperlipidemic active agent and one or more conventional carrier(s), and (b) a second pharmaceutical composition containing a hydroximic acid derivative of the formula I and one or more conventional carrier(s). The pharmaceutical combination is suitable for the prevention or treatment of, among others, diabetes mellitus.

The invention refers to a synergistic pharmaceutical combinationsuitable for the prevention or treatment of a prediabetic state,metabolic X-syndrome or diabetes mellitus as well as disorders which areassociated with the states listed above, namely endogenic metabolicdisorders, insulin resistance, dislipidemia, alopecia, diffuse effluviumand/or female endocrinic disorders based on androgenic preponderance.

In the industrially developed countries more and more human beingsuffers from diabetes. For example, the development of type 2 diabetes(i.e. non-insulin-dependent diabetes mellitus, NIDDM) is promoted by thedefects in both the production and use of insulin. Genetic andenvironmental factors equally contribute to the formation of thiswide-spread serious disease accompanied by significant mortality. Thepatient treated with insulin or another antidiabetic oranti-hyperlipidemic agent obtains, as a matter of fact, only apalliative treatment that improves the life quality, however, thecomplications which accompany the diabetes appear unavoidably.

The aim of the invention is to provide a pharmaceutical combinationwhich is suitable for the prevention of the development of diabetes orat least the complications that accompany diabetes, or, if suchprevention is not possible anymore, for the efficient treatment of saidcomplications.

It was found that the above aim is achieved by a synergisticpharmaceutical combination comprising

-   (a) a first pharmaceutical composition containing an antidiabetic or    anti-hyperlipidemic active agent and one or more conventional    carrier(s), and-   (b) a second pharmaceutical composition containing a hydroximic acid    derivative of the formula    wherein-   R¹ represents a hydrogen atom or a C₁₋₅ alkyl group,-   R² stands for a hydrogen atom, a C₁₋₅ alkyl group, a C₃₋₈ cycloalkyl    group or a phenyl group optionally substituted by a hydroxy or a    phenyl group, or-   R¹ and R² together with the nitrogen atom they are attached to form    a 5- to 8-membered ring optionally containing one or more further    nitrogen, oxygen or sulfur atom(s) and said ring can be condensed    with another alicyclic or heterocyclic ring, preferably a benzene,    naphthalene, quinoline, isoquinoline, pyridine or pyrazoline ring,    furthermore optionally the nitrogen and/or sulfur heteroatom(s)    is/are present in the form of an oxide or dioxide,-   R³ means a hydrogen atom, a phenyl group, a naphthyl group or a    pyridyl group wherein said groups can be substituted by one or more    halo atom(s) or C₁₋₄ alkoxy group(s),-   Y is a hydrogen atom, a hydroxy group, a C₁₋₂₄ alkoxy group    optionally substituted by an amino group, a C₂₋₂₄ poly-alkenyloxy    group containing 1 to 6 double bond(s), a C₁₋₂₅ alkanoyl group, a    C₃₋₉ alkenoyl group or a group of the formula R⁷—COO—wherein R⁷    represents a C₂₋₃₀ polyalkenyl group containing 1 to 6 double    bond(s),-   X stands for a halo atom, an amino group, a C₁₋₄ alkoxy group or-   X forms with B an oxygen atom, or-   X and Y together with the carbon atom they are attached to and the    —NR—O—CH₂— group being between said carbon atoms form a ring of the    formula    wherein    -   Z represents an oxygen atom or a group of the formula —N═or        —NH—,-   R stands for a hydrogen atom or-   R forms with B a chemical bond,-   A is a C₁₋₄ alkylene group or a chemical bond or a group of the    formula    wherein    -   R⁴ represents a hydrogen atom, a C₁₋₅ alkyl group, a C₃₋₈        cycloalkyl group or a phenyl group optionally substituted by a        halo atom, a C₁₋₄ alkoxy group or a C₁₋₅ alkyl group,    -   R⁵ stands for a hydrogen atom, a C₁₋₄ alkyl group or a phenyl        group,    -   m has a value of 0, 1 or 2,    -   n has a value of 0, 1 or 2,        or a pharmaceutically suitable acid addition salt thereof, and        one or more conventional carrier(s).

The invention is based on the recognition that the hydroximic acidderivatives of the formula I enhance the sensitivity of insulin.Therefore, in the presence of a hydroximic acid derivative of theformula I or a pharmaceutically suitable acid addition salt thereof, theantidiabetic or anti-hyperlipidemic active agent employed for thetreatment of the pathological state can be administered in asignificantly lower dosage to achieve the aimed effect, thereby reducingor eliminating the side-effects that accompany the traditionaltreatment.

The hydroximic acid derivatives of the formula I are known from U.S.Pat. No. 4,308,399 and EP No. 417 210. According to these documents, thecompounds can be employed for the treatment of diabetic angiopathy, anda part of them has selective beta-blocking effect.

According to Hungarian patent application No. 2385/92 published underNo. T/66350, certain hydroximic acid derivatives within the formula Ican be used in the treatment of vascular complications due to diabetes.

Various further biological effects of the hydroximic acid derivatives ofthe formula I are also known, among others the use thereof for theprevention and treatment of diseases of mitochondrial origin (WO97/13504), for enhancing the stress protein level of cells (WO97/16439), for delaying the aging processes of skin (WO 97/23198),against autoimmune diseases (WO 00/07580) etc.

DEFINITION OF EXPRESSIONS USED IN THE DESCRIPTION AND CLAIMS

A pharmaceutical combination is an association of two pharmaceuticallyactive agents in which

-   1) either each of the active agents has been converted, one by one,    to separate pharmaceutical compositions using one or more    conventional carrier(s) and any of the usual processes of drug    manufacture, and in this case the two sorts of pharmaceutical    composition obtained are administered to the patient simultaneously    or one after the other following an interval;-   2) or the two active agents have been converted to one single    pharmaceutical composition that can be administered to the patient    being in need thereof. In the latter case, the pharmaceutical    composition may contain a mixture of the two active agents, or each    of the active agents may be present at a different site in the    pharmaceutical composition, e.g. one of them in the tablet core and    the other in a coating of the tablet core. Of course, one or more    conventional carriers and any of the usual processes of drug    manufacture are used to prepare this single pharmaceutical    composition.

Under an antidiabetic active agent any of the pharmacologically activeagents conventionally used in the therapy for the treatment of diabetesis meant. These are mainly the following:

-   -   insulin,    -   insulin sensitizing active agents,    -   active agents that enhance the production of insulin,    -   sulfonamides,    -   biguanidine derivatives and    -   α-glucosidase inhibitors.

As insulin, in the first place, human insulin prepared by recombinanttechnology is employed, which is administered, in general, parenterally.

The insulin sensitizing active agents enhance the effect of insulin. Themost important sorts of them are the PPAR (peroxisomeproliferator-activated receptor) γ-agonists, for example thethiazolidinedione derivatives such as pioglitazone[(±)-5-[[4-[2-(5-ethyl-2-pyridinyl)ethoxy]phenyl]methyl]-2,4-thiazolidinedione],troglitazone[(±)-5-[[4-[(3,4-dihydro-6-hydroxy-2,5,7,8-tetramethyl-2H-1-benzopyran-2-yl)methoxy]-phenyl]methyl]-2,4-thiazolidinedione],ciglitazone[5-[[4-[(1-methylcyclohexyl)methoxy]phenyl]methyl]-2,4-thiazolidine-dione,rosiglitazone[(±)-5-[4-[2-[N-methyl-N-(2-pyridyl)amino]-ethoxy]benzyl]-2,4-thiazolidinedione]and other 2,4-thiazolidinedione derivatives as well as pharmaceuticallysuitable acid addition salts thereof.

The active agents that enhance the production of insulin are, forexample, as follows: mitiglinide [(αS,3aR,7aS)-octahydro-γ-oxo-α-(phenylmethyl)-2H-isoindole-2-butanoic acid],repaglinide[(S)-2-ethoxy-4-[2-[[3-methyl-1-[2-(1-piperidinyl)phenyl]butyl]amino]-2-oxoethyl]benzoicacid], senaglinide (i.e. nateglinide) [N-[[(trans-4-(1-methylethyl)-cyclohexyl]carbonyl]-D-phenylalanine] or pharmaceutically suitable acidaddition salts or pharmaceutically suitable salts thereof.

Out of the sulfonamides, the most important ones are the sulfonylureaderivatives e.g. tolbutamide[N-[(butylamino)-carbonyl]-4-methylbenzenesulfonamide], chlorpropamide[4-chloro-N-[(propylamino)carbonyl]benzenesulfonamide], tolazamide[N-[[(hexahydro-1H-azepin-1-yl)amino]carbonyl]-4-methylbenzenesulfonamide],acetohexamide [4-acetyl-N-[(cyclohexylamino)carbonyl]benzenesulfonamide]etc. as first generation sulfonylureas or, for example, glyburide[5-chloro-N-[2-[4-[[[(cyclohexylamino)carbonyl]amino]sulfonyl]phenyl]-ethyl]-2-methoxybenzamide],glipizide[N-[2-[4-[[[(cyclohexyl-amino)carbonyl]amino]sulfonyl]phenyl]ethyl]-5-methylpyrazine-carboxamide],gliclazide[N-[[(hexahydrocyclopenta[c]pyrrol-2(1H)-yl)amino]carbonyl]-4-methylbenzenesulfonamide],glimepiride[trans-3-ethyl-2,5-dihydro-4-methyl-N-[2-[4-[[[[(4-methylcyclohexyl)amino]carbonyl]amino]sulfonyl]phenyl]ethyl]-2-oxo-1H-pyrrole-1-carboxamide], gliquidone[N-[(cyclohexyl-amino)carbonyl]-4-[2-(3,4-dihydro-7-methoxy-4,4-dimethyl-1,3-dioxo-2(1H)-isoquinolinyl)ethyl]benzenesulfonamide],glibornuride[N-[[(3-hydroxy-4,7,7-trimethylbicyclo[2.2.1]hept-2-yl)amino]carbonyl]-4-methylbenzenesulfonamide],glisoxepid[N-[2-[4-[[[[(hexahydro-1H-azepin-1-yl)amino]carbonyl]amino]-sulfonyl]phenyl]ethyl]-5-methyl-3-isoxazolecarboxamide],glibencla mide[5-chloro-N-[2-[4-[[[(cyclohexylamino)carbonyl]-amino]sulfonyl]phenyl]ethyl]-2-methoxybenzamide],glisentide[N-[2-[4-[[[(cyclopentylamino)carbonyl]amino]sulfonyl]phenyl]-ethyl]-2-methoxybenzamide],glisolamide[N-[2-[4[[[(cyclohexyl-amino)carbonyl]amino]sulfonyl]phenyl]ethyl]-5-methyl-3-isoxazolecarboxamide],glybuzole[N-[5-(1,1-dimethylethyl)-1,3,4-thiadiazol-2-yl]benzenesulfonamide],glyclopyramide[4-chloro-N-[(1-pyrrolidinylamino)carbonyl]benzenesulfonamide] etc. assecond generation sulfonylureas and pharmaceutically suitable acidaddition salts thereof.

The most important biguanidine derivatives can be characterized by theformula

wherein

-   R⁸, R⁹, R¹⁰ and R¹¹ represent, independently, a hydrogen atom, a    C₁₋₁₀ alkyl group, a naphthyl group, a phenyl group or a phenyl(C₁₋₄    alkyl) group, wherein in both former cases the phenyl group is    optionally substituted by 1-3 substituents which can be,    independently, a halo atom, a C₁₋₄ alkyl group or a C₁₋₄ alkoxy    group,    with the proviso that-one of R⁸, R⁹, R¹⁰ and R¹¹ is other than a    hydrogen atom, or-   R⁸ and R⁹ together with the adjacent nitrogen atom and/or R¹⁰ and    R¹¹ together with the adjacent nitrogen atom form a 5- or    6-membered, saturated, unsaturated or aromatic ring that can be    fused with a further 5- or 6-membered saturated, unsaturated or    aromatic ring optionally containing also a nitrogen atom.

Especially preferred biguanidine derivatives are metformin[N,N-dimethylimidocarbonimidic diamide], buformin[N-butylimidodicarbonimidic diamide] and phenformin[N-(2-phenylethyl)imidodicarbonimidic diamide].

The α-glucosidase inhibitors inhibit the enzyme α-glucosidase. Importantrepresentants thereof are, for example, miglitol[1,5-dideoxy-1,5-[(2-hydroxyethyl)imino]-D-glucitol], acarbose[O-4,6-dideoxy-4-[[[1S-(1α,4α,5β,6α)]-4,5,6-trihydroxy-(3-hydroxymethyl)-2-cyclohexen-1-yl]amino]-α-D-glucopyranosyl-(1→4)-O-α-D-glucopyranosyl-(1→4)-D-glucose],voglibose[3,4-dideoxy4-[[2-hydroxy-1-(hydroxymethyl)ethyl]amino]-2-C-(hydroxymethyl)-D-epiinositol]etc.

Under an anti-hyperlipidemic active agent any of the pharmacologicallyactive agents conventionally used in the therapy for the treatment ofhigh blood-lipid level is meant.

These are compounds that can be classified mainly as follows:

-   -   aryloxyalkanoic acid derivatives,    -   HMG coenzyme reductase inhibitors,    -   nicotinic acid derivatives,    -   antacids for bile acids.

Out of the aryloxyalkanoic acid derivatives, preferred active agents aree.g. clofibrate [2-(4-chlorophenoxy)-2-methyl-propanoic acid ethylester], gemfibrozil [5-(2,5-dimethyl-phenoxy) -2,2-dimethylpentanoicacid], simfibrate [2-(4-chloro-phenoxy) -2-methylpropanoic acid1,3-propanediyl ester], etofibrate [3-pyridinecarboxylic acid2-[2-(4-chlorophenoxy)-2-methyl -1-oxopropoxy]ethyl ester], ciprofibrate[2-[4-(2,2-dichlorocyclopropyl)phenoxy]-2-methylpropanoic acid],ronifibrate [3-pyridinecarboxylic acid 3-[2-(4-chlorophenoxy)-2-methyl-1-oxopropoxy]propyl ester] etc.

Out of the HMG coenzyme reductase inhibitors, the most important activeagents are the following: lovastatin [[1S-[1α(R*),3α,7β,8β(2S*,4S*),8αβ]]-2-methylbutanoic acid1,2,3,7,8,8α-hexahydro-3,7-dimethyl-8-[2-(tetrahydro-4-hydroxy-6-oxo-2H-pyran-2-yl)ethyl]-1-naphthalenyl ester], fluvastatin[[R*,S*-(E)]-(±)-7-[3-(4-fluorophenyl)-1-(1-methyl-ethyl)-1H-indol-2-yl]-3,5-dihydroxy-6-heptenoic acid], pravastatin[[1S-[1α(βS*,δS*),2α,6α,8β(R*),8aα]]-1,2,6,7,8,8a-hexahydro-β,δ,6-trihydroxy-2-methyl-8-(2-methyl-1-oxobutoxy)-1-naphthaleneheptanoicacid monosodium salt], simvastatin[[1S-[1α,3α,7β,8β(2S*,4S*),8αβ]]-2,2-dimethylbutanoic acid1,2,3,7,8,8a-hexahydro-3,7-dimethyl-8-[2-(tetrahydro-4-hydroxy-6-oxo-2H-pyran-2-yl)ethyl]-1-naphthalenyl ester], atorvastatin [[R-(R*,R*)]-2-(4-fluorophenyl)-β,δ-dihydroxy-5-(1-methylethyl)-3-phenyl-4-[(phenylamino)carbonyl]-1H-pyrrole-1-heptanoic acid] etc.

Out of the nicotinic acid derivatives, for example, the following onesare used: acipimox [5-methylpyrazinecarboxylic acid 4-oxide], niceritrol[3-pyridinecarboxylic acid2,2-bis[[(3-pyridinylcarbonyl)oxy]methyl]-1,3-propanediyl ester],nicomol [3-pyridinecarboxylic acid (2-hydroxy-1,3-cyclohexane-diylidene)-tetrakis(methylene) ester], nicoclonate [3-pyridine-carboxylic acid1-(4-chlorophenyl)-2-methylpropyl ester] etc.

Out of the antacids that bind the bile acids, important ones are thefollowing: colestipol [a basic anion exchange resin: N-(2-aminoethyl)-N′-[2-[(2-aminoethyl)amino]-ethyl]-1,2-ethane-diamine polymer with(chloromethyl)oxirane], cholestyramine [a synthetic, strongly basicanion exchange resin containing quaternary ammonium functional groupswhich are attached to a styrene-divinylbenzene copolymer], polidexide[an anion exchange resin containing quaternary ammonium groups whichbind the bile acids in the intestine] etc.

The antidiabetic and anti-hyperlipidemic active agents are known fromthe literature. If desired and chemically possible, these active agentscan be used in the form of the pharmaceutically suitable acid additionsalts thereof or in the form of the salts formed with pharmaceuticallysuitable bases.

In the description and claims a C₁₋₄ alkyl group is a methyl, ethyl,n-propyl, isopropyl, n-butyl, sec.-butyl, tert.-butyl or isobutyl group.

A C₁₋₅ alkyl group may be, in addition to the ones listed above, e.g. ann-pentyl group, too.

A C₁₋₄ alkoxy group can be, for example, a methoxy, ethoxy, n-propoxy orn-butoxy group.

A halo atom is, for example, a fluoro, chloro, bromo or iodo atom.

A C₃₋₈ cycloalkyl group stands e.g. for a cyclopropyl, cyclo-pentyl,cyclohexyl, cycloheptyl or cyclooctyl group.

The 5- to 8-membered ring containing a nitrogen atom and which maycontain a further heteroatom is, for example, a pyrrole, pyrazole,imidazole, oxazole, thiazole, pyridine, pyridazine, pyrimidine,piperazine, morpholine, indole, quinoline ring or the like.

A C₁₋₂₄ alkoxy group can be, in addition to the alkoxy groups listedabove, e.g. also a n-pentoxy, decyloxy, dodecyloxy, octadecyloxy groupetc.

A C₁₋₂₅ alkanoyl group is, for example, a formyl, acetyl, propionyl,butyryl, caproyl, palmitoyl, stearoyl group etc.

A C₃₋₉ alkenoyl group is e.g. an acryloyl, pentenoyl, hexenoyl,heptenoyl, octanoyl group etc.

When Y represents a group of the formula R⁷—COO—, it can be, forexample, a linolenoyl, linoloyl, docosahexaenoyl, eicosapentaenoyl,arachidonoyl group etc.

When R³ stands for a pyridyl group, if desired, the nitrogen atomthereof may be in the form of the N-oxide. Similarly, when

R¹ and R² form with the adjacent nitrogen atom a 5- to 8-membered ring,for example a piperidyl ring, if desired, the nitrogen atom thereof canbe also present in the form of an N-oxide.

Under a pharmaceutically suitable acid addition salt, an acid additionsalt formed with a pharmaceutically suitable inorganic acid such ashydrogen chloride or sulfuric acid and the like, or with apharmaceutically suitable organic acid such as acetic acid, fumaricacid, lactic acid and the like is meant.

When the antidiabetic or anti-hyperlipidemic active agent has a chemicalstructure that can form a salt with a base, also the salt of the activeagent formed with a pharmaceutically suitable inorganic or organic basecan be used. When said active agent can form an acid addition salt withan acid, a pharmaceutically suitable acid addition salt of the activeagent can be employed, too.

Within the hydroximic acid derivatives of the formula I, a preferredsubclass consists of the hydroximic acid derivatives of the formula

wherein R¹, R², R³, R⁴, R⁵, m and n are as defined for formula I, Xstands for a halo atom or an amino group, Y represents a hydroxy group,and pharmaceutically suitable acid addition salts thereof.

The hydroximic acid derivatives of the formula II, wherein R¹ and R²form, together with the adjacent nitrogen atom, a piperidino group, R³is a pyridyl group, both m and n have a value of 0, X is as definedabove, and pharmaceutically suitable acid addition salts thereof areparticularly preferred. Out of them,O-(3-piperidino-2-hydroxy-1-propyl)nicotinic amidoxime andpharmaceutically suitable acid addition salts, particularly themonohydrochloride or dihydrochloride thereof are especially preferred.

Another advantageous subclass of the hydroximic acid derivatives of theformula I consists of the compounds of the formula

wherein R¹, R², R³ and A are as defined for the formula I, andpharmaceutically suitable acid addition salts thereof.

A further preferred subclass of the hydroximic acid derivatives of theformula I consists of the cyclic compounds of the formula

wherein R¹, R², R³ and A are as defined for the formula I, Z representsan oxygen atom or a group of the formula —N═or —NH—, andpharmaceutically suitable acid addition salts thereof.

A still further preferred subclass of the hydroximic acid derivatives ofthe formula I consists of the compounds of the formula

wherein R¹, R², R³ and A are as defined for the formula I, R⁶ stands fora C₁₋₄ alkyl group, and pharmaceutically suitable acid addition saltsthereof.

The compounds of the formula I can be prepared by using processes knownfrom U.S. Pat. No. 4,308,399, EP No. 417 210 and Hungarian patentapplication laid open under No. T/66350.

In the synergistic pharmaceutical combination of the invention the mass(or weight) ratio of (a) the antidiabetic or anti-hyperlipidemic activeagent or, if desired and chemically possible, a pharmaceuticallysuitable acid addition salt or a salt formed with a pharmaceuticallysuitable base thereof and (b) the hydroximic acid derivative of theformula I or a pharmaceutically suitable acid addition salt thereof is,in general, (1-100):(100-1). The one or two pharmaceuticalcomposition(s) of the pharmaceutical combination is/are suitable forperoral or parenteral administration and is/are solid or liquidcomposition(s). The suitable dosage forms and manufacture thereof aswell as the useful carriers are known from the literature e.g.Remington's Pharmaceutical Sciences, Mack Publishing Co., Easton, USA.

Preferably, the synergistic pharmaceutical combination of the inventioncomprises (a) a hydroximic acid derivative of the formula II or apharmaceutically suitable acid addition salt thereof and (b) anantidiabetic or anti-hyperlipidemic active agent or, if desired andchemically possible, a pharmaceutically suitable acid addition salt or asalt formed with a pharmaceutically suitable base thereof, wherein theactive agents are present in separate pharmaceutical compositions or ina single common pharmaceutical composition. The antidiabetic oranti-hyperlipidemic active agent can be, for example, one of the specieslisted above. Thus, the preferred synergistic pharmaceutical combinationof the invention may contain (a) a hydroximic acid derivative of theformula II e.g. O-(3-piperidino-2-hydroxy-1-propyl)nicotinic amidoximeor a pharmaceutically suitable acid addition salt thereof such as thedihydrochloride or monohydrochloride as well as (b₁) an antidiabeticactive agent e.g. insulin, or an insulin sensitizing active agent suchas a thiazolidinedione derivative, for example, pioglitazone,troglitazone, ciglitazone, rosiglitazone, or an active agent thatenhance the production of insulin such as mitiglinide, repaglinide,senaglinide, or a sulfonamide such as tolbutamide, chlorpropamide,tolazamide, acetohexamide, glyburide, glipizide, gliclazide,glimepiride, gliquidone, glibornuride, glisoxepid, glibenclamide,glisentide, glisolamide, glybuzole, glyclopyramide, or a biguanidinederivative of the formula VI, preferably metformin, buformin,phenformin, or an α-glucosidase inhibitor such as miglitol, acarbose orvoglibose, or (b₂) an anti-hyperlipidemic active agent e.g. anaryloxyalkanoic acid derivative such as clofibrate, gemfibrozil,simfibrate, etofibrate, ciprofibrate, ronifibrate, or a HMG coenzymereductase inhibitor such as lovastatin, fluvastatin, pravastatin,simvastatin, atorvastatin, or a nicotinic acid derivative such asacipimox, niceritrol, nicomol, nicoclonate, or an antacid for bile acidssuch as colestipol, cholestyramine, polidexide, or, if desired andchemically possible, a pharmaceutically suitable acid addition salt or asalt formed with a pharmaceutically suitable base of the species givenunder (b₁) and (b₂).

Another preferred pharmaceutical combination of the invention comprises(a) a compound of the formula III, IV or V or a pharmaceuticallysuitable acid addition salt thereof, as well as (b₁) an antidiabeticactive agent e.g. insulin, or an insulin sensitizing active agent suchas a thiazolidinedione derivative, for example, pioglitazone,troglitazone, ciglitazone, rosiglitazone, or an active agent thatenhance the production of insulin such as mitiglinide, repaglinide,senaglinide, or a sulfonamide such as tolbutamide, chlorpropamide,tolazamide, acetohexamide, glyburide, glipizide, gliclazide,glimepiride, gliquidone, glibornuride, glisoxepid, glibenclamide,glisentide, glisolamide, glybuzole, glyclopyramide, or a biguanidinederivative of the formula VI, preferably mefformin, buformin,phenformin, or an a-glucosidase inhibitor such as miglitol, acarbose orvoglibose, or (b₂) an anti-hyperlipidemic active agent e.g. anaryloxyalkanoic acid derivative such as clofibrate, gemfibrozil,simfibrate, etofibrate, ciprofibrate, ronifibrate, or a HMG coenzymereductase inhibitor such as lovastatin, fluvastatin, pravastatin,simvastatin, atorvastatin, or a nicotinic acid derivative such asacipimox, niceritrol, nicomol, nicoclonate, or an antacid for bile acidssuch as colestipol, cholestyramine, polidexide, or, if desired andchemically possible, a pharmaceutically suitable acid addition salt or asalt formed with a pharmaceutically suitable base of the species givenunder (b₁) and (b₂).

The influence of the combination of the invention on the glucosesensitivity was studied using the following tests. All experimentsperformed conform to the European Community guiding principles for thecare and use of experimental animals.

Adult male New Zealand white rabbits weighing 3-3.2 kg, housed in ananimal room (12-hour light/dark periods a day, temperature of 22-25 °C., relative humidity of 50-70%) with one animal per pen, fed commerciallaboratory chow and tap water ad libitum, were used throughout. Theanimals underwent surgery after a two-week adaptation period.

Surgery was performed under aseptic conditions. The rabbits wereanaesthetized with an intravenous bolus of 10 mg/kg diazepam (Sigma, St.Louis, Mo., USA) and 5 mg/kg ketamine (EGIS Pharmaceuticals Ltd.,Budapest, Hungary). Lidocaine (EGIS Pharmaceuticals Ltd., Budapest,Hungary) was administered subcutaneously for local pain relief asdescribed by Szilvassy Z. et al., Br. J. Pharmacol., 112, 999-1001(1994). Polyethylene catheters were inserted into two major branches ofthe jugular vein and the left carotid artery. The catheters wereexteriorised through the back of the neck. These lines were kept patentby filling with sodium heparin solution (100 IU/ml).

Hyperinsulinaemic Euglycaemic Glucose Clamp Studies

Human regular insulin was infused at a constant rate (13 mU/kg, NOVONordisk, Copenhagen) via one of the venous catheters over 120 min. Thisinsulin infusion yielded plasma insulin immunoreactivity of 100±5 μU/mlin the steady state. This value corresponds to five times the value ofthe normal upper limit. Blood samples (0.3 ml) were taken from thearterial cannula for blood glucose concentration at 10 min intervals.Blood glucose concentration was maintained constant (5.5±0.5 mmol/litre)by a variable rate of glucose infusion via the second venous cannula.When blood glucose had stabilized for at least 30 min, we defined thiscondition as steady state. In the steady state, additional blood samples(0.5 ml) were taken for plasma insulin determination at 10-minintervals. The glucose infusion rate (mg/kg/min) during steady state wasused to characterize insulin sensitivity [DeFronzo R.A. et al., Am. J.Of Physiol., 237, E214-223 (1979)]. The test compound(s) was/wereadministered to healthy and hypercholesterolaemic animals, respectively,perorally, in a single dose, daily, for five days, and the glucoseinfusion rates determined on the 6^(th) day were averaged within eachtest group consisting of 6 animals. One group of the healthy and one ofthe hypercholesterolaemic animals was used as the control. The resultsobtained are shown in Tables 1 and 2. TABLE 1 Insulin sensitivity ascharacterized by the glucose infusion rate in mg/kg/min during steadystate BGP-15 BGP-15 Metformin (30 mg/kg) + Group of 30 mg/kg 100 mg/kgmetformin animals Control daily dose p.o. daily dose p.o. (100 mg/kg)normal 14.6 ± 1.03 15.9 ± 1.82 15.8 ± 0.83 18.1 ± 0.92 HC 9.7 ± 1.0 13.4± 1.11 11.7 ± 0.87 15.8 ± 0.75normal = healthy animals were used in the test;HC = hypercholesterolaemic animals were used in the test;BGP-15 = O-(3-piperidino-2-hydroxy-1-propyl)nicotinic amidoximehydrochloride.

TABLE 2 Insulin sensitivity as characterized by the glucose infusionrate in mg/kg/min during steady state BGP-15 BGP-15 Troglitazone (30mg/kg) + Group of 30 mg/kg 75 mg/kg troglitazone animals Control dailydose p.o. daily dose p.o. (75 mg/kg) normal 13.9 ± 1.22 15.4 ± 1.26 14.3± 0.08  16.9 ± 1.04 HC  9.0 ± 0.84 13.8 ± 1.29 14.1 ± 1.33 16.07 ± 0.84normal = healthy animals were used in the test;HC = hypercholesterolaemic animals were used in the test;BGP-15 = O-(3-piperidino-2-hydroxy-1-propyl)nicotinic amidoximehydrochloride.

As a matter of fact, the amount of glucose infused to obtain constantblood glucose level has been measured in the above tests. It isfavourable that a higher amount of glucose should be needed at the givenconstant blood glucose level which indicates the enhanced effect ofinsulin. Consequently, the higher glucose infusion rate is measured, thehigher efficiency is obtained with the compound tested.

As seen in Table 1, in healthy animals, of course, higher values areobtained than in hypercholesterolaemic ones. In the control groups,lower glucose infusion rates are experienced than in the groups treatedwith either BGP-15 or metformin. Anyway, in both healthy andcholesterolaemic animals, the glucose infusion rates are significantlyhigher when the animals has been treated with both BGP-15 and metforminthan in the case when only one of the test compounds has beenadministered. Thus, synergism is observed between BGP-15 and metformin.

The situation is the same with BGP-15 and troglitazone as shown by Table2.

The invention includes also a method for the treatment or the preventionof a prediabetic state, metabolic X-syndrome or diabetes mellitus aswell as disorders which are associated with the above states, namely,endogenic metabolic disorders, insulin resistance, dislipidemia and/orfemale endocrinic disorders based on androgenic preponderance, in whichthe patient suffering from or threatened by said states is treated witha therapeutically effective amount of, on the one hand, an antidiabeticor anti-lipidemic active agent, or, if desired and chemically possible,a pharmaceutically suitable acid addition salt or a salt formed with apharmaceutically suitable base thereof, on the other hand, a hydroximicacid derivative of the formula I, or a pharmaceutically suitable acidaddition salt thereof.

The antidiabetic or anti-hyperlipidemic active agent and the hydroximicacid derivative of the formula I can be administered simultaneously orone after the other following a shorter interval lasting for e.g. someseconds or minutes or a longer interval lasting for e.g. 10-30 minutes.

Since the hydroximic acid derivative of the formula I synergisticallyenhances the therapeutical effect of the antidiabetic oranti-hyperlipidemic active agent, in the process of the invention thedaily dose of the antidiabetic or anti-hyperlipidemic agent is lowerthan the usual daily dose thereof employed in the conventional treatmentwhen no hydroximic acid derivative of the formula I is administered.

Using the process of the invention, the development of especially thefollowing clinical patterns can be prevented, or, when once developed,they can be influenced advantageously:

-   prediabetic state such as glucose intolerance or insulin resistance,-   metabolic X-syndrome,-   both types of diabetes (IDDM and NIDDM),-   diabetic complications with special regards to retinopathy,    neuropathy, nephropathy, polycystic ovary syndrome (PCOS), gestation    diabetes mellitus (GDM), arterial hypertonia, dislipidemia,    arteriosclerosis, obesitas, cardial ischemia associated with    diabetes etc.

Thus, the invention includes the use of a hydroximic acid derivative ofthe formula I or a pharmaceutically suitable acid addition salt thereoffor the preparation of a pharmaceutical composition which enhancessynergistically the effect of an active agent, especially anantidiabetic or anti-hyperlipidemic active agent, employed for theprevention or treatment of a prediabetic state, metabolic X-syndrome ordiabetes mellitus as well as disorders which are associated with theabove states, namely endogenic metabolic disorders, insulin resistance,dislipidemia, alopecia, diffuse effluvium and/or female endocrinicdisorders based on androgenic preponderance. Consequently, thepharmaceutical composition containing a hydroximic acid derivative ofthe formula I or a pharmaceutically suitable acid addition salt thereofas the active agent can be administered to a patient being treated withan antidiabetic or anti-hyper-lipidemic active agent in order to preventor treat a prediabetic state, metabolic X-syndrome or diabetes mellitusas well as disorders which are associated with the above states, namelyendogenic metabolic disorders, insulin resistance, dislipidemia,alopecia, diffuse effluvium and/or female endocrinic disorders based onandrogenic preponderance. The administration of the pharmaceuticalcomposition containing a hydroximic acid derivative of the formula I ora pharmaceutically suitable acid addition salt thereof as the activeagent results in a lower dosage of the antidiabetic oranti-hyperlipidemic active agent. When a pharmaceutical compositioncontaining a hydroximic acid derivative of the formula I or apharmaceutically suitable acid addition salt thereof, for example,O-(3-piperidino-2-hydroxy -1-propyl)nicotinic amidoxime or apharmaceutically suitable acid addition salt such as the dihydrochlorideor the mono-hydrochloride thereof as the active agent is administered toa patient suffering from diabetes and obtaining a regular insulintreatment, then the daily insulin dose can be reduced, thus, avoidingthe development of insulin resistance.

1. A synergistic pharmaceutical combination for the prevention ortreatment of a prediabetic state, metabolic X-syndrome or diabetesmellitus as well as disorders which are associated with the stateslisted above, namely endogenic metabolic disorders, insulin resistance,dislipidemia, alopecia and/or diffuse effluvium comprising: (a) a firstpharmaceutical composition containing an antidiabetic active agentselected from the group consisting of insulin, peroxisomeproliferator-activated receptor γ-agonists, sulfonylurea derivatives andbiguanidine derivatives or an anti-hyperlipidemic active agent, namely aHMG coenzyme reductase inhibitor or, if desired and chemically possible,a pharmaceutically suitable acid addition salt or a salt formed with apharmaceutically suitable base thereof and one or more conventionalcarrier(s), and (b) a second pharmaceutical composition containingO-(3-piperidino-2-hvdroxy-1-propyl)nicotinic amidoxime or apharmaceutically suitable acid addition salt thereof, and one or moreconventional carrier(s).


2. A pharmaceutical combination of claim 1, in which a singlepharmaceutical composition comprises both the antidiabetic oranti-hyperlipidemic active agent or, if desired and chemically possible,a pharmaceutically suitable acid addition salt or a salt formed with apharmaceutically suitable base thereof, and theO-(3-piperidino-2-hydroxy-1-propyl) nicotinic amidoxime or apharmaceutically suitable acid addition salt thereof, in addition to oneor more conventional carrier(s).
 3. A pharmaceutical combination ofclaim 1 or 2, comprising insulin.
 4. A pharmaceutical combination ofclaim 1 or 2 comprising pioglitazone, troglitazone, ciglitazone,rosiglitazone, tolbutamide, chlorpropamide, tolazamide, acetohexamide,glyburide, glipizide, gliclazide, glimepiride, gliquidone, glibornuride,glisoxepid, glisentide, glisolamide, glybuzole, glyclopyramide,metformin, buformin, phenformin, lovastatin, fluvastatin, pravastatin,simvastatin, or atorvastatin, or, if desired and chemically possible, apharmaceutically suitable acid addition salt or a salt formed with apharmaceutically suitable base thereof as the antidiabetic oranti-hyperlipidemic active agent.
 5. A pharmaceutical combination ofclaim 3 comprising troglitazone. glyburide, metformin or atorvastatinor, if desired and chemically possible, a pharmaceutically suitable acidaddition salt or a salt formed with a pharmaceutically suitable basethereof as the antidiabetic or anti-hyperlipidemic active agent.
 6. Apharmaceutical composition comprisingO-(3-piperidino-2-hydroxy-1-propyl)nicotinic amidoxime or apharmaceutically suitable acid addition salt thereof, which enhancessynergistically the effect of an antidiabetic active agent selected fromthe group consisting of insulin, peroxisome proliferator-activatedreceptor γ-agonists, sulfonylurea derivatives and biguanidinederivatives or an anti-hyperlipidemic active agent namely a HMG coenzymereductase inhibitor, wherein said pharmaceutical composition is employedfor the prevention or treatment of a prediabetic state, metabolicX-syndrome or diabetes mellitus as well as disorders which areassociated with the above states, namely, endogenic metabolic disorders,insulin resistance, dislipidemia, alopecia and/or diffuse effluvium. 7.A method for the prevention or treatment of a prediabetic state,metabolic X-syndrome or diabetes mellitus as well as disorders which areassociated with the above states, namely, endogenic metabolic disorders,insulin resistance, dislipidemia, alopecia and/or diffuse effluvium, inwhich the patient suffering from or threatened by said states is treatedwith a therapeutically effective amount of, on the one hand, anantidiabetic active agent selected from the group consisting of insulin,peroxisome proliferator-activated receptor γ-agonists, sulfonylureaderivatives and biguanidine derivatives or an anti-hyperlipidemic activeagent namely a HMG coenzyme reductase inhibitor or, if desired andchemically possible, a pharmaceutically suitable acid addition salt or asalt formed with a pharmaceutically suitable base thereof, and, on theother hand, O-(3-piperidino-2-hydroxy-1-propyl)nicotinic amidoxime or apharmaceutically suitable acid addition salt thereof.
 8. A synergisticpharmaceutical combination of claim 1 comprising metformin or apharmaceutically suitable acid addition salt or a salt formed with apharmaceutically suitable base thereof.
 9. A pharmaceutical combinationof claim 1, comprising troglitazone or a pharmaceutically suitable acidaddition salt or a salt formed with a pharmaceutically suitable basethereof.
 10. A pharmaceutical combination of claim 1, comprisingglibenclamide or a pharmaceutically suitable acid addition salt or asalt formed with a pharmaceutically suitable base thereof.
 11. Apharmaceutical combination of claim 1, comprising lovastatin or apharmaceutically suitable acid addition salt or a salt formed with apharmaceutically suitable base thereof.